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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDFO� 7�6 ¢ S C�' �'S <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Arco - Manteca <br /> SITE ADDRESS 1100S Main St Manteca 95337 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 825-6784 Z'Z — 'fp — 6 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 09-6 S Gc <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEPHONE# EXT. <br /> Service Station Testing -SST INC �51 �6ZSZa 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 ( 209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: fl—p t.-- - rte DATE: 8/7/13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® President <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Replaced 89 STP sump sensor ( L-5 ) due to intermittent sensor out alarms PAYMENT <br /> RECEIVED <br /> AUG 1 2 ?x-13 <br /> SAN JOAQUIN COUNTY <br /> ENVIHOMENTAL <br /> ACCEPTED BY: ` nA_ EMPLOYEE M 2b ?v ATEP 3Z: <br /> ASSIGNED TO: ` EMPLOYEE#: D D / DATE: / <br /> Date Service Completed (if already comple : 8/7/13 SERVICE CODE: P/E• <br /> Fee Amount: �'� Amount Paid 3 �So v Payment Date o./ p✓2 <br /> Payment Type Vr' Invoice# Check# &113 3 Received By: <br /> 4464-1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />